Gestational diabetes mellitus (GDM) is diabetes that develops during pregnancy and can cause complications for both the mother and baby if not properly managed. The case presentation describes a 30-year-old pregnant woman with decreased fetal movement at 36 weeks of pregnancy who has a history of GDM. Management of GDM focuses on tight glycemic control through diet, exercise, blood glucose monitoring and possibly insulin to prevent complications like premature delivery, macrosomia, hypoglycemia and jaundice in the baby. Both mother and baby require close monitoring during and after pregnancy.

1. DIABETES IN PREGNANCY

2.  CASE PRESENTATION
 DR GITANJALI KUMARI
 MODERATOR- DR SALIL BARSODE

3.  My patient,30 years old, Gravida 3 para 2 living 1 Dead 1,with 9 months of
amenorrhea came to Bharati hospital with c/o decreased fetal movements since
1 day such that she perceived only 1-2 fetal movements in 1 day. She is known
case of Gestational diabetes mellitus with previous LSCS
 No complaint of pain in abdomen or tightness of abdomen
 No complaint of PV leaking mucoid discharge

4.  Menstrual history
LMP-3/10/20 (wrong dates)
PMH-10-15 days/3-4 months/irregular
Gestation age-36 Weeks 4 days (busg @ 12wk 6d on 20/1/20)
EDD-28/7/2019

5.  OBSTETRIC HISTORY
Married since 11 years
Non consanguineous marriage
G1- FTVD, BOY ,10 YRS, 2.5KG
G2-FTLSCS i/v/o MSL ,GIRL,NND ON DAY 2 OF LIFE
G3-Present pregnancy, registered @BH, INJ TT1 @TT2 taken, diagnosed with
GDM @5TH M.A ->Started on tab METFORMIN 250MG BD

6.  FIRST TRIMESTER-
First visit @ 1.5 months of amenorrhea, pregnancy was confirmed by UPT &
ultrasound.
Routine check up was done & it was normal
No h/o excessive nausea or vomiting or admission
SECOND TRIMESTER-
A scan was done & it was normal
h/o raised BSL levels, hence started on MNT AND TAB METFORMIN 250MG BD
Vaccination taken
THIRD TRIMESTER-

7.  No h/o excessive weight gain or raised BP during pregnancy
 No h/o fever, burning micturition,headache,blurring of vision or epigastric pain
during pregnancy
 No h/o admission during pregnancy

8.  PAST HISTORY-no history of diabetes mellitus or hypertension prior to
pregnancy
 FAMILY HISTORY-no family history of diabetes in first degree relative

9. EXAMINATION
 GENERAL PHYSICAL EXAMINATION
Height-154cm Weight-60kg BMI-25.2
P-84bpm;BP-120/80mmHg in right radial artery
No pallor,edema
RS-airway entry equal on both sides, no basal crepitations,
CVS-S1 S2 normal

10.  PER ABDOMEN EXAMINATION-
INSPECTION-
Abdomen longitudinally ovoid
Linea nigra,stria gravidarum seen
Previous LSCS (transverse) scar seen
PALPATION-
Uterus- 36 WK
Relaxed

11. Fundal grip-soft,non ballotable part s/o breech
Lateral grip-Irregular, knob like structure on right side s/o limbs; smooth, curved
shaped structure on left side s/o back
Pawlik grip-hard,globular,ballotable structure s/o head
Pelvic grip-hands converging-head not engaged
AUSCULTATION-
FHS +,regular,148bpm on left spinoumbilical line

12.  Diagnosis-Gravida 3 para 1 living 1 dead 1with 36 weeks 4 days pregnancy
with gestational diabetes mellitus with previous LSCS with decreased fetal
movements under observation

13. INTRODUCTION
 Diabetes is a disorder of carbohydrate metabolism. It is caused by combination
of hereditary & environmental factors.
 Characterized by either inadequate secretion or inadequate action of insulin
 Abnormal maternal glucose regulation occurs in about 3-10 % of pregnancy
 Prevalence of Gestational diabetes-18%

14.  Reasons for rise in prevalence of diabetes
1.Changes in lifestyle
2.Dietary habits
3.Older age at first conception
4.Pcos
5.Obesity

15. PRE-GESTATIONAL OR
OVERT
DIABETES BEFORE
PREGNANCY
CRITERIA FOR DIAGNOSING OVERT
DM
GESTATIONAL
DIABETES
DIAGNOSED FIRST
IN PREGNANCYBLOOD GLUCOSE
FASTING >/=126
HBa1C >/=6.5 %
BSL R >/=200
IADPSG 2010 consensus panel
CLASSIFICATION OF DIABETES

16. CLASSIFICATION

17. WHITE CLASSIFICATION
• Provide information on pregnancy risk and prognosis
• Advancing stages of white classification inversely related to favourable
pregnancy outcome
Class Onset Fasting 2 hour PP Therapy
A1 GESTATIONAL <105 <120 DIET
A2 GESTATIONAL >105 >120 INSULIN

18. Class Age on onset
(YRS)
Duration (YRS) Vascular Therapy
B OVER 20 <10 - INSULIN
C 10 TO 19 10 TO 19 - INSULIN
D <10 >20 BENIGN
RETINOPAT
HY
INSULIN
F ANY ANY NEPHROPATHY
(PROTEINURIA
>/= 500 MG IN
24 HRS
BEFORE 20
WEEKS)
INSULIN
R ANY ANY PROLIFERAT
IVE
RETINOPATH
Y
INSULIN
H ANY ANY HEART DISEASE INSULIN

19. GESTATIONAL DIABTES MELLITUS
 Any degree of glucose intolerance that either commences or first diagnosed in
pregnancy
 According to IADPSG 2010 guidelines, diabetes first recognised in pregnancy
can be classified as ‘gestational’ or ‘overt’.
 Criteria for diagnosis of overt diabetes include any of the following
• Fasting plasma glucose >/= 126 mg/dl
• Hba1c >/=6.5 %
• Random plasma glucose >200mg/dl along with confirmation by fasting glucose
or HBA1C levels

20. SCREENING & DIAGNOSIS OF GDM
 The most basic elaborate regimen for screening includes
• Either fasting or random blood glucose during first visit
• Screening glucose challenge test at 24-28 weeks
• Followed by oral glucose challenge test if the test results are outside normal
limits

21. DIPSI RECOMMENDATION
 SINGLE STEP DIAGNOSTIC PROCEDURE FOR ALL PATIENTS(UNIVERSAL
SCREENING)
 75 GRAM LOADING GLUCOSE CHALLENGE TEST
 2 HOUR BSL LEVELS-
o <120-normal
o 120-139-DGGT
o 140-200-GDM
o >200-overt DM

22. • Single step testing using 75 gram oral glucose and measuring
blood sugar 2 hours after ingestion.
• 75 gm glucose is to be given orally after dissolving in approx.
300 ml water whether the pregnant women comes in fasting or
non fasting state, irrespective of the last meal. The intake of
the solution has to be completed within 5- 10 minutes.
• If vomiting occurs within 30 minutes of oral glucose intake , the
test has to be repeated the next day.
• The threshold blood sugar level of >/= 140 mg/dl is taken as
cut off for diagnosis of GDM.

23. Testing for GDM at 1st antenatal visit ( 75 g oral
glucose
– 2 hr blood sugar value)
Positive
(2 hr BS>/= 140 mg/dl)
Negative ( 2 hrs BS
<140 mg/dl)
MANAGE AS GDM AS
PER
GUIDELINES
REPEAT TESTING AT 24
–28 WEEKS
IF NORMAL
MANAGE AS
NORMALANC

24. 2 stepapproach
• Recommended by ACOG,2001
• Universal screening for GDM
• This can be done either by patient history clinical risk factor , or 50 gm one hour loading test at
24-28 weeks.
• For diagnosis 100 gm 3 hour OGTT is done
• Risk factors for GDM should be assessed and accordingly glucose testing isdone.

25. O’ SULLIVAN
TEST
50 gm GCT irrespective
of
time of day and
previous
meal
Venous BSL at 1
hour
130 mg/dl
Sensitivity -90%
Number of false positive
increases
140 mg/dl
Sensitivity -
80%
100 gm diagnostic test 3 hour OGTT
• Done after overnight fasting of 8-14 hrs
• During previous 3 days there must be unrestricted diet(
150 g carbohydrate atleast /day)
• Unlimited physical activity
• Patient must be seated through out and not smoking
• 100 gm anhydrous glucosegiven
• Blood withdrawn at hourly intervals- 3 samples
• 2 or more values shouldbe abnormal
Carpenter and
Coustan
criteria
Fasting-95
1 hour-180
2 hour- 155
3 hour- 140
National
diabetes data
group( NDDG)
Fasting- 105
1 hour- 190
2 hour- 165
3 hour- 145

26. 5TH INTERNATIONAL WORKSHOP
CONFERENCES IN
GDM

27. LOW
RISK
MODERATE
RISK
HIGH
RISK
• Age<25 years
• Member of any ethnic
group with low
prevalence of GDM
• No history of diabetesin
1st
degree relative
• No history of
abnormal glucose
metabolism
• Weight normal before
pregnancy
• Weight normal at birth
• Age<25 years
• Member of an ethnic
group with high
prevalence of GDM
• Diabetes in 1st
degree relative
• Overweight prior
to pregnancy
• Weight high at birth
GLUCOSE TESTING
DONEAT 24-28
WEEKS.
• Marked obesity
• Strong family historyof
type 2 DM
• Previous history of GDM
or impaired glucose
tolerance or glycosuria
or macrosomic baby
GLUCOSE TESTING
DONEAS SOON AS
POSSIBLE
1 step2 step
NO
SCREENING

28. FIFTH INTERNATIONAL WORKSHOP
CONFERENCE ON GDM (NOVEMBER 2005)
CLASSIFICATION

29. • NICE GUIDELINES OF 2008 RECOMMEND SCREEING USING RISK FACTORS IN
HEALTHY POPULATION
• Includes-
1. BMI >30 kg/sq m
2. Previous baby >4.5 kg
3. 1st degree relative DM
4. Ethnicity
 2 hour 75 gm OGTT to be used to test GDM at 24- 28weeks
 Diagnosis made on WHO criteria
• Fasting >/=126 mg/dl
• 2 hour- 140 mg/dl
 Women with previous GDM should be offered OGTT at 16-18 w e e k s repeatat 24- 28 weeks

30. Single step approach(75 gm OGTT)
Recommended by American diabetic association (ADA) and International association of
diabetes and pregnancy study groups( IADPSG).
• Cutoffs-
Fasting- >/=92 mg/dl
Post 1 hour- >/= 180 mg/dl
Post 2 hours- >/= 153 mg/dl
• These cut offs are lower than the traditional values.
• These are considered after HAPO study which suggests increased complications even below the
traditional cut- offs used for diagnosis of GDM.

31. ADA AND IADPSG 2011
CRITERIA?

32. • 2011, IADPSG and ADA recommended
- Test all women at the first visit before 13 weeks OR Test women with any 1 risk factor
• BMI >25
• Previous baby > 4kg @ birth
• h/o GDM, unexplained still birth, malformation PCOS, heart disease, Hypertension, dyslipidemia
• non-Caucasian
• medications that raise glucose (steroids, beta mimetics, atypical
antipsychotic)
• First degree relative with DM
•

33. Overt GDM
HBA1c >6.5 5.7-6.4 <5.7
Fasting >/=126 >/=92-125 <92
random >/=200
OGTT AT 24-28
WEEKS
IF
ABNORMAL
GDM
IF 1ST VISIT AFTER 13 WEEKS AND RISK FACTORS PRESENT
OGTT AS SOON AS POSSIBLE

34. MANAGEMENT
 PREPREGNANCY
Women in reproductive age group with diabetes should undergo complete health
check-up & preconceptional counselling
Main aim-to achieve optimal glycaemic control
Renal, cardiovascular & retinal examination to rule out end organ damage
NICE guidelines 2008-therapy must be targeted to achieve prepregnancy HbA1C
level less than 6.1%.If HbA1C level more than 10% avoid pregnancy

35. ANTENATAL MANAGEMENT
 ADA recommends BSL F < 95mg/dl,1 hour < 140mg/dl,2 hours <120mg/dl
 Fetal ultrasound parameters to modify treatment strategies
o 1.AC >95th centile-BSL F <80mg/dl & PP <100mg/dl
o 2.AC <95th centile-BSL F <100mg/dl & PP <140 mg/dl

36.  1.SELF BLOOD GLUCOSE MONITORING-required wherein intensification of
treatment is required
 2.MNT(Medical nutritional therapy)-first line therapy
 3.EXERCISE
 4.PHARMACOTHERAPY
• INSULIN-gold standard in treatment of GDM.
• Combination of short acting + intermediate acting insulin is recommended
• Dose of insulin-0.7-1U/kg/day
• Total daily insulin requirement=2/3rd in morning + 1/3rd at night
• morning dose=2/3rd NPH + 1/3rd short acting
• Night dose=1/2 NPH + ½ short acting

37.  OHA(Oral hypoglycaemic agents)-Metformin & Glyburide
 5.FETAL SURVEILLANCE IN DIABETES-
FIRST TRIMESTER-dating scan, FTS
SECOND TRIMESTER-A scan,fetal 2 D echo,uterine artery doppler
THIRD TRIMESTER-4 weekly monitoring of fetal growth from 28-32
weeks,DFMC,BPP
6.TIMING OF DELIVERY-completed 38 weeks
Uncomplicated cases-till 40 weeks

38. MANAGEMENT DURING LABOUR
1.Consent
2.Cross match
3.Two IV lines to be secured
4.In case of induction of labour ,evening meal & insulin to be taken. Morning
dose of insulin to be omitted. BSL fasting to be done
5.If blood glucose level not maintained,then dextrose-insulin neutralising drip
to be started.50 units of regular insulin in 50 ml normal saline is started.10 %
dextrose drip @125ml/hr to be continuously given
6.Monitoring
7.Second stage-if needed instrumental delivery must be undertaken with care
8.Baby-evaluation by neonatologist

39. 9.Watch for postpartum haemorrhage
SPECIAL PRECAUTIONS DURING CAESAREAN-
1.Adequate incision size
2.Use of forceps to deliver high floating head
3.Check for suture extension

40. POSTPARTUM MANAGEMENT
 Insulin can be stopped after delivery if BSL levels are
normal.Pregestational diabetics-continue insulin for a while & then shift
to pre conceptional medication
 Wound care
 Prolonged antibiotic in case of complicated caesarean or instrumental
delivery
 Testing of BSL levels @6-12 weeks postpartum.If normal-3 yearly
assessment.If abnormal-MNT/pharmacotherapy

41. What are the complications
associated with diabetes during
pregnancy?
MATERN
AL
FET
AL

42. FetalEffects
• Spontaneous abortions – 25 %
• Preterm delivery- 28 %
• Malformations – 11 %
• Altered Fetal Growth (Macrosomia-
32%)
• Unexplained fetal demise
• Polyhydramnios -20%
• Respiratory distress syndrome
• Neonatal hyperbilirubinemia
• Neonatal polycythemia
• Hypocalcemia and hypomagnesemia
• Hypoglycemia , hypothermia

43. •Late
complications
Obesity
Type 2 DM
Type 1 DM (3-5%)
Cardiovascular diseases
Impair cognitive and motor
function.

44. Maternal Complications
 CHRONIC
 MICROVASCULAR
• Neuropathy
• Nephropathy
• Retinopathy
 Macrovascular
• Coronary artery diseases and
cardiomyopathy
• Stroke
• PVD
ACUTE
Hyperglycemia
with ketoacidosis
Hypoglycemia

45. • Diabetic retinopathy
1st and most common visible lesion  small
microaneurysms
Form hard exudates Blot
haemorrhages (non proliferative retinopathy)
As disease advances vessels get
occluded
Retinal ischemia and infarctions
Cotton wool
exudates
proliferative retinopathy (
require laser
Managed with
good glycemic
control.

46. • In known diabetics , fundoscopy is recommended at 1st antenatal
visit
Norma
l repeat at 28
weeks
abnormal
repeat at 16-20
weeksAs such retinopathy is not a contraindication for vaginal delivery,
but in cases of untreated proliferative retinopathy
labor
increase intra ocular pressure intravitreal haemorrhage
In cases of proliferative retinopathy ophthalmic follow up is done
for 6 months.

47. Diabetic neuropathy
• In the form of gastropathy
increase gastric emptying time.
Nausea, vomiting, nutritional
problems. Managed with 
metoclopramide
Dopamine receptor antagonist
Gastric neurostimulators
• Peripheral symmetrical sensorimotor is uncommon in
pregnant women

48. Infections
• Candidal vulvovaginitis
• Urinary and respiratory tract
infections
• Asymptomatic bacteuria
• Wound complications post
operatively
• Puerperal and pelvic sepsis

49. • Diabetic Ketoacidosis-DKA –1 %
 Most common in type 1 diabetes
Risk factors-
• Hyperemesis gravidarum
• Infection
• Insulin noncompliance
• Beta mimitic drug for tocolysis
• Corticosteroids for lung maturation
• Febrile illness, dehydration
• Diarrhoeal disease

50. Symptoms Signs
• Polyuria,thirst
• Weight loss
• Weakness
• Nausea,vomiting
• Blurred vision
• Abdominal pain, leg cramps
• Dehydration
• Hypotension, tachycardia
• Cold extremities/peripheral cyanosis
• Air hunger (kussmaul breathing)
• Smell of acetone
• Hypothermia
• Confusion, drowsiness,coma
DKA

51. GLUCONEOGEN
ESIS
INCREASE INSULIN
RESISTANCE
Stres
s
FATTYACIDS
USED
HYPERGLYCEMIA
DUE TO UNDER
UTILIZATIONAND
OVER PRODUCTION
METABOL
IC
ACIDOSI
S
KETONE
BODIES
FORMATIO
N
OSMOTIC
DIURESIS
COMPENSATO
RY
HYPERVENTILAT
ION
KETONEMIA
KETONURIA SWEET
ODOUR OF BREATH DEHYDRATI
ON
MATERNAL
AND FETAL
DISTRESS

52. MANAGEMENT
• CBC, ABG,ECG,CXR,SE,BSL,SERUM
AND URINE
KETONES
LAB
S • BSL>250 MG/DL
• KETONE BODIES IN BLOOD AND
URINE
• ARTERIAL pH <7.43
• S.BICARBONATE <15MEQ/L
DIAGNO
SIS
• LOW DOSE
• LOADING 0.2 TO 0.4UNITS/KG
• MAINTENANCE– 2-10 U/HR
(0.1U/KG/HR)
INSULI
N

53. FLUID
S
Isotonic sodium
chloride
4-6 l replaced in
1st 12 hrs.
1 l in 1st hour
500-1000 ml /hr
in next 2-4 hrs
250 ml/hr until 80
% replaced.
Glucos
e
Once BSL
reaches
250
mg/dl start 5
% dextrose
in normal
saline
Potassium
infusion
If normal or
decrease start
15-20 meq/hr
infusion
If raised once get
normal start 20-
30 meq/l in iv
solution
Bicarbonat
e
If pH <7.1
give44 meq in 1l
of
0.45 %
normal
saline

54. Hypoglycemia
• BSL <70 mg/dl.
• Early- tremors of hands, sweating, palpitations, hunger, easy
fatiguability, headache, tingling sensations around mouth and
lips.
• Severe- confusion, abnormal behaviour, visual
disturbances, nervousness, anxiety.
• Management:
Early oral fast acting carbohydrate followed by complex
carbohydrate snack, is sufficient.
1 mg glucagon IM
10% dextrose infusion

55. THANK YOU